After a second wave of intensive household testing, a large study of the "test and treat" strategy in Zambia is diagnosing more people with HIV, getting more people onto treatment, and reducing the time between diagnosis and starting treatment, findings from the PopART study presented at the recent Conference on Retroviruses and Opportunistic Infections (CROI 2017) show.

PopART, also known as HPTN 071, is a large community-randomized trial being carried out in Zambia and KwaZulu-Natal, South Africa. The study is comparing the impact on HIV incidence of household-based HIV testing and linkage to care by community HIV care providers (CHiPs), and immediate initiation of antiretroviral treatment delivered through routine health care services, to the standard of care.

PopART is an important test of the feasibility of offering testing and treatment at a very large scale, essential for achievement of the UNAIDS 90-90-90 target of 90% of people with HIV diagnosed, 90% of diagnosed people on treatment, and 90% of those on treatment virally suppressed.

PopART investigators reported on progress towards achieving the 90-90-90 goals in the second round of the study in Zambia, from June 2015 to October 2016, in communities randomized to receive household visits. Each round of the study consists of visits to all households in the community to offer home-based HIV counseling and testing and, in Round 2, to make contact with everyone diagnosed with HIV in Round 1, to ensure that they had been linked to care and remain in HIV care.

After the first round of the study, 53% of people diagnosed with HIV in Zambia had started treatment within 12 months. In Round 2, 45,616 households were visited and 95% consented to take part in the study, comprising 110,755 adults (65% of men and 87% of women actually underwent testing). The higher frequency of testing among women was due to the fact that women were more likely to be contacted at home than men.

The researchers produced an estimate for the total number of adults living with HIV based on the prevalence of HIV among those who were tested (9.8% in men and 16.1% in women). They concluded that 6249 men and 10,341 women were living with HIV, and that 78% of men and 90% of women with HIV had been diagnosed.

Although men with HIV remained less likely to be diagnosed than women after Round 2, there was substantial improvement in the level of diagnosis in men. By the end of Round 2 the proportion of men in all age groups diagnosed with HIV had risen above 70%, compared to less than 60% of those in the under-35 age groups being diagnosed after Round 1. Men over 40 remained more likely to be aware of their HIV status after Round 2.

Among women the age difference in diagnosis evident after the first round had largely disappeared after Round 2. Almost 90% of women knew their HIV status in all age groups after Round 2.

After Round 2, 78% of diagnosed men and 79% of diagnosed women were estimated to be taking antiretroviral therapy (ART). Young men and women were less likely to be on treatment, but uptake of treatment improved for both women and men in Round 2. Among those who reported that they had started treatment prior to the beginning of Round 2, 92% of men and 95% of women were still taking ART at the time they were contacted to take part in Round 2.

The speed at which people started treatment after having been referred for HIV care also improved in Round 2. Whereas it took study participants a median of 9.5 months to start treatment after referral in Round 1, this interval was reduced to 5 months in Round 2. The investigators attribute this improvement to an increased focus among community HIV care providers on ensuring linkage to care and improved coordination with clinics to ensure linkage.

S Floyd, M Phiri, A Schaap, et al. ART coverage after two years of a UTT intervention in Zambia: findings from HPTN071. Conference on Retroviruses and Opportunistic Infections. Seattle, February 13-16, 2017. Abstract 1010.